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Somatoform Dissociation
Ellert R. S. Nijenhuis PhD
To cite this article: Ellert R. S. Nijenhuis PhD (2001) Somatoform Dissociation, Journal
of Trauma & Dissociation, 1:4, 7-32, DOI: 10.1300/J229v01n04_02
To link to this article: http://dx.doi.org/10.1300/J229v01n04_02
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Somatoform Dissociation:
Major Symptoms of Dissociative Disorders
Ellert R. S. Nijenhuis, PhD
Ellert R. S. Nijenhuis
10
nates among various diagnostic categories, (5) depends on culture, (6) reflects general psychopathology, (7) depends on suggestion, (8) is characteristic of dissociative disorders, and can be used in the screening for these
disorders, (9) is associated with (reported) trauma among psychiatric patients
and patients presenting in medical health care settings, and (10) relates to
animal defense-like reactions. The review of these studies is preceded by
brief descriptions of Janets view on hysteria and Myers (1940) view on
shell shock, or war-related traumatization.
JANETS CLASSIFICATION OF DISSOCIATIVE SYMPTOMS
Janets clinical observations suggested that hysteria involves psychological and somatoform functions and reactions (Janet, 1889, 1893, 1901/1977).
In his view, mind and body were inseparable, thus his classification of the
symptoms of hysteria does not follow a mind-body distinction. He maintained that apart from the permanent symptoms, termed mental stigmata,
that mark all cases of hysteria, there are incidental symptoms, that is, symptoms that depend on each case. Janet referred to these intermittent and variable symptoms as mental accidents (Van der Hart & Friedman, 1989).
Janet observed that mental stigmata include functional losses including
partial or complete loss of knowledge (amnesia), loss of sensations such as
loss of tactile sensations, kinesthesia, smell, taste, hearing, vision, and pain
sensitivity (analgesia), and loss of motor control (inability to move or speak).
We have referred to mental stigmata as negative symptoms (Nijenhuis & Van
der Hart, 1999).
Janet defined mental accidents as incidental symptoms, i.e., symptoms
that vary by case and are often more transitory in nature. In our view, mental
accidents represent positive symptoms because they involve additions, i.e.,
mental phenomena that should have been integrated in the personality, but
because of integrative failure become dissociated material that intrudes into
consciousness at times. Examples include reexperiencing more or less complete traumatic memories and manifestations of dissociative personalities.
According to Janet, the simplest form of mental accidents are ides
fixes (fixed ideas), that are related to intrusions of some dissociated emotion, thought, sensory perception, or movement. This intrusion into or interruption of the personality may also pertain to hysterical attacks, to the
extent to which they are reactivations of traumatic memories. Janet observed
that some disssociative patients are subject to somnambulisms, which
today may be recognized as the activities of dissociative identities (APA,
1994). (Since these mental structures involve far more than merely a different
sense of self, we feel they are better referred to as dissociative personalities
Ellert R. S. Nijenhuis
11
(Nijenhuis, Van der Hart, & Steele, in press).) When patients lose all touch
with reality during dissociative episodes, they experience a delirium, i.e., a
reactive dissociative psychosis (Van der Hart, Witztum, & Friedman, 1993).
Janet (1889, 1893, 1901/1977, 1907) gave many clinical examples showing that dissociative mental structures can involve dissociated sensory, motor,
and other bodily reactions and functions in addition to dissociated emotions
and knowledge. The symptoms can vary within each dissociative mental
structure. For example, in one dissociative personality the patient may be
insensitive to pain (analgesic) or touch (tactile anesthesia), but in another,
these mental stigmata can be absent, or exchanged for mental accidents, such
as localized pain. Whatever has not been integrated into one dissociative
personality (not-knowing; not-sensing; not-perceiving) is often prominent in
another: a memory; a thought; a bodily feeling, or a complexity of sensations,
motor reactions, and other experiential components that could manifest in
hysterical attacks.
Janets dissociation theory postulates that both somatoform and psychological components of experience, reactions, and functions can be encoded
into mental systems that can escape integration into the personality (Janet,
1889, 1893, 1901/1977, 1911). He used the construct personality to denote
the extremely complex, but largely integrated, mental system that encompasses consciousness, memory, and identity. Janet observed that dissociative
mental systems are also characterized by a retracted field of consciousness,
that is, a reduced number of psychological phenomena that can be simultaneously integrated into one and the same mental system.
In Janets conceptualization, mental accidents represent reactivations of
what has been encoded and stored in dissociative systems of ideas and
functions. Due to recurrent dissociation and imagery, these systems can
become emancipated. That is, dissociative systems may synthesize and assimilate more sensations, feelings, emotions, thoughts, and behaviors in the
context of recurrent traumatization or reactivation by trauma-related conditioned stimuli. As a result, these systems may become associated with a range
of experiences, a name, age, and other personality-like characteristics. Today,
these emancipated systems are described as more or less complex dissociative personalities whose personality-like features may result from secondary
elaborations (Nijenhuis, Spinhoven, Vanderlinden, Van Dyck, & Van der
Hart, 1998). These elaborations are probably promoted by hypnotic-like
imagination, restricted fields of consciousness, and needs that are associated with these dissociative mental systems. To a yet unknown extent, secondary shaping of dissociative mental systems by sociocultural influences
may also be involved (Gleaves, 1996; Janet, 1929; Laria & Lewis-Fernndez,
in press).
12
Ellert R. S. Nijenhuis
13
Somatoform dissociation
Mental stigmata, or
negative dissociative
symptoms
Amnesia
Abulia
Modifications of character
(loss of character traits,
predominantly affects)
Suggestibility
Mental accidents, or
positive dissociative
symptoms
Subconscious acts,
hysterical accidents, and
fixed ideas
Subconscious acts,
hysterical accidents, and
fixed ideas: singular
intrusive somatoform
symptoms which
influence the habitual
state
Hysterical attacks
Hysterical attacks:
complexes of
somatoform symptoms
which influence the
habitual state
Somnambulism
Somnambulism: alterations
of state, which involve
complex somatoform
alterations
Deliriums (dissociative
psychosis)
Deliriums: alterations of
state, which involve
grotesque somatoform
alterations and enduring
failure to test reality
SDQ-20 include negative and positive symptoms, and converge with the
major symptoms of hysteria formulated by Janet a century ago. Examples of
sensory losses are analgesia (Sometimes my body, or a part of it, is insensitive to pain), kinesthetic anesthesia (Sometimes it is as if my body, or a
part of it, has disappeared), and motor inhibitions (Sometimes I am paralysed for a while; Sometimes I cannot speak, or only whisper). Anesthesia also pertains to visual (Sometimes I cannot see for a while), and
auditory perception (Sometimes I hear sounds from nearby as if they were
coming from far away). Positive symptoms include Sometimes I have pain
while urinating, and Sometimes I feel pain in my genitals (at times other
than sexual intercourse).
In seven studies performed to date, age and gender did not have a significant effect on somatoform dissociation as measured by the SDQ-20. However, in a sample of psychiatric outpatients (N = 153), women had slightly
higher scores than men (Nijenhuis, Van der Hart, & Kruger, submitted), and
14
in Turkey, a weak but statistically significant correlation with age was found
(Sar, Kundakci, Kiziltan, Bakim, & Bozkurt, 2000, this issue).
SOMATOFORM DISSOCIATION
AND PSYCHOLOGICAL DISSOCIATION
In all but one study performed to date, somatoform dissociation was
strongly associated with psychological dissociation as measured by the DES
and DIS-Q, ranging from r = 0.62 (Nijenhuis et al., submitted) to r = 0.85
(Nijenhuis, Van Dyck, Spinhoven et al., 1999). Waller et al. (2000, this issue)
found a lower correlation among psychiatric outpatients in the United Kingdom (r = 0.51). These results suggest that while somatoform and psychological dissociation are manifestations of a common process, they are not completely overlapping. Somatoform and psychological dissociation during or
immediately after the occurrence of a traumatic event, i.e., peritraumatic
dissociation, were also significantly correlated (Nijenhuis, Van Engen et al.,
in press).
SOMATOFORM DISSOCIATION IN VARIOUS DIAGNOSTIC
GROUPS IN THE NETHERLANDS AND BELGIUM
A range of contemporary studies have revealed that somatoform dissociation is a unique construct and a major feature of dissociative disorders
(Nijenhuis et al., 1996, 1998a; Nijenhuis, Van Dyck, Spinhoven et al., 1999).
Patients with DSM-IV dissociative disorders had significantly higher
SDQ-20 scores than psychiatric outpatients with other DSM-IV diagnoses,
and patients with dissociative identity disorder (DID) had higher scores than
patients with dissociative disorder, not otherwise specified (DDNOS) or depersonalization disorder (Nijenhuis et al., 1996, 1998a).
In Dutch samples, the SDQ-20 discriminated among various diagnostic
categories (Nijenhuis, Van Dyck, Spinhoven et al., 1999). Compared to patients with DDNOS or depersonalization disorder, patients with DID had
significantly higher scores. Patients with DDNOS had statistically significantly higher scores than patients with somatoform disorders or eating disorders, and the latter two diagnostic categories were associated with significantly higher scores than patients who had anxiety disorder, depression,
adjustment disorders and bipolar mood disorders (see Table 2). In particular,
bipolar mood disorder was associated with extremely low somatoform dissociation (see also Nijenhuis, Spinhoven, Van Dyck, Van der Hart, De Graaf
et al., 1997).
Ellert R. S. Nijenhuis
15
Turkish samples
North American
samples
mean
SD
mean
SD
mean
DID
27
15
23
51.8
57.3
55.1
12.6
14.9
13.5
25
58.7
17.9
11
50.7 10.7
Dell: DID
> DDNOS,
eating disorder,
pain disorder
23
16
21
43.8
44.6
43.0
7.1
11.9
12.0
25
46.3
16.2
47
31.9
9.4
Pseudo-epilepsy
27
29.8
7.5
Epilepsy
74
24.8
6.9
26
26.8
6.4
23
28.7
8.3
22
22.7
3.5
49
24.3
6.8
Eating disorders
50
27.7
8.8
45
22.9
3.9
Anxiety disorder
Major depressive episode
Bipolar mood disorder
51
22.9
3.7
52
25.6
9.3
SD
In contrast with the SDQ-20, the DES did not discriminate between bipolar mood disorder and somatoform disorders. In a sample that primarily
included cases of DSM-IV conversion and pain disorder and no cases of
hypochondriases, the results suggest that patients with these particular somatoform disorders have significant somatoform dissociation, but less psychological dissociation (Nijenhuis, Van Dyck, Spinhoven et al., 1999).
IS SOMATOFORM DISSOCIATION
A CULTURALLY-DEPENDENT PHENOMENON?
Our consistent finding that somatoform dissociation is extremely characteristic of DSM-IV dissociative disorders, in particular DID, has been corrob-
16
orated by findings in some other countries and cultures (see Table 2). In the
USA, Chapperon (personal communication, September 1996) found high
somatoform dissociation among DID patients, and Dell (1997a) reported that
DID patients had significantly higher scores than patients with DDNOS,
eating disorders, or pain disorder. Studying various diagnostic categories in
Turkey, Sar and colleagues (Sar, Kundakci, Kiziltan, Bahadir, and Aydiner,
1998; Sar et al., 2000, this issue) obtained results that are remarkably similar
to ours: somatoform dissociation was extreme in DSM-IV dissociative disorders, quite modest in anxiety disorders, major depression, and schizophrenia,
and low in bipolar mood disorder. Also consistent with our data, both Dell
(1997a) and Sar et al. (1998, 2000, this issue) found strong intercorrelations
of SDQ-20 and DES scores. Van Duyls (personal communication, March
2000) data on somatoform dissociation among dissociative disorder patients
in Uganda converge with our Dutch/Flemish results as well. Conjointly, these
international findings suggest that somatoform dissociation is highly characteristic of dissociative disorders, that somatoform and psychological dissociation are closely related constructs, and that the severity of somatoform
dissociation among dissociative disorder patients from these cultures is largely comparable. Moreover, somatoform dissociative symptoms and disorders
also manifested among tortured Bhutanese refugees, in particular those with
PTSD (Van Ommeren et al., in press).
Ellert R. S. Nijenhuis
17
18
Ellert R. S. Nijenhuis
19
predicted psychological dissociation. According to the reports of the dissociative disorder patients, this abuse usually occurred in an emotionally neglectful and abusive social context. Both somatoform and psychological
dissociation were best predicted by early onset of reported intense, chronic
and multiple traumatization.
Reanalysing the data of this study, it was found that the total TEC score
explained 48% of the variance of somatoform dissociation, a value that
exceeded the variance explained by reported physical and sexual abuse (Nijenhuis, 1999). This additional finding suggests that somatoform dissociation is
strongly associated with reported multiple types of trauma: a finding that
converges with the results of research in the incidence of verified multiple
and chronic traumatization in DID patients (Coons, 1994; Hornstein & Putnam, 1992; Kluft, 1995; Lewis, Yeager, Swica, Pincus, & Lewis, 1997).
Studying psychiatric outpatients, both Waller and his colleagues (2000,
this issue) and Nijenhuis et al. (submitted) also found that among various
types of trauma, somatoform dissociation was best predicted statistically by
physical abuse and threat to life by another person. Preliminary North American findings (Dell, 1997b) have indicated moderate to strong statistically
significant correlations among somatoform dissociation and reported sexual
abuse (r = .51), sexual harassment (r = .49), physical abuse (r = .49), and
lower correlations with reported emotional neglect (r = .25) and emotional
abuse (r = .31). Reported early onset of traumatization was somewhat more
strongly associated with somatoform dissociation than was trauma reported
in later developmental periods, and among all variables tested the total trauma score was associated with somatoform dissociation most strongly (r =
.63). These various results are highly consistent with our findings. It can be
concluded that somatoform dissociation is particularly associated with physical abuse and sexual trauma, thus with threat to the integrity of the body.
Consistent with this conclusion, Van Ommeren et al. (in press) found that
tortured Bhutanese refugees (N = 526), compared with nontortured Bhutanese refugees, had significantly more lifetime ICD-10 (WHO, 1992) persistent somatoform pain disorder (56.2% vs. 28.8%), dissociative motor disorder (11.2% vs. 1.3%), and dissociative anesthesia and sensory loss (14.4% vs.
2.8%).
A link between somatoform dissociation and reported trauma is also suggested by studies that have found associations between somatization symptoms, somatoform disorders and reported trauma. For example, undifferentiated somatoform disorder belonged to the three DSM-IV Axis I diagnoses
that marked Gulf War veterans referred for medical and psychiatric syndromes (Labbate, Cardea, Dimitreva, Roy, & Engel, 1998). More specifically, reports of traumatic events were correlated with both PTSD and somatoform diagnoses, and veterans who handled dead bodies had a three-fold risk
20
Ellert R. S. Nijenhuis
21
patients with other psychiatric diagnoses. Those expressive of the hypothesized similarityfreezing, anesthesia-analgesia, and disturbed eatingbelonged
to the five most characteristic symptoms of dissociative disorder patients.
Anesthesia-analgesia, urogenital pain and freezing symptom clusters independently contributed to predicted caseness of dissociative disorder. Using an
independent sample, it appeared that anesthesia-analgesia best predicted
caseness after controlling for symptom severity. The indicated symptom clusters correctly classified 94% of cases that constituted the original sample, and
96% of the independent second sample. These results were largely consistent
with the hypothesized similarity.
The anesthesia symptoms characterize emotional personalities, but may
also be part and parcel of apparently normal personalities. In our view,
apparently normal personalities are phobic of traumatic memories and
phobic of the associated emotional personalities (Nijenhuis & Van der
Hart, 1999; Nijenhuis, Van der Hart et al., in press). This phobia manifests in
two major negative dissociative symptoms: amnesia and sensory, as well as
emotional anesthesia. Recent data from psychobiological experimental research with both types of dissociative personalities support this interpretation
(Nijenhuis, Quak et al., 1999; Van Honk, Nijenhuis, Hermans, Jongen, & Van
der Hart, 1999).
IS SOMATOFORM DISSOCIATION ALSO ASSOCIATED
WITH DISSOCIATIVE DISORDER AND TRAUMA
IN A NONPSYCHIATRIC POPULATION?
In order to test the generalizability of the powerful associations between
somatoform dissociation, dissociative disorder, and reported trauma among
psychiatric patients, we investigated whether these relationships would also
hold among a nonpsychiatric population (Nijenhuis, Van Dyck, Ter Kuile et
al., 1999). According to the literature, chronic pelvic pain (CPP) is one of the
somatic symptoms that, at least among a subgroup of gynecology patients,
relates to reported trauma (e.g., Walling et al., 1994; Walker et al., 1995) and
dissociation (Walker et al., 1992). In this population (N = 52), psychological
dissociation and somatoform dissociation were significantly associated with
(features of) DSM-IV dissociative disorders, as measured by the SCID-D.
Anxiety, depression, and psychological dissociation best predicted the SCIDD total score, whereas amnesia was best predicted by somatoform dissociation. Identity confusion was best predicted by anxiety/depression and somatoform dissociation. These findings ran partly contrary to our hypothesis that
somatoform dissociation among CPP patients would be more predictive of
dissociative disorder than psychological dissociation.
In this study, the sensitivity of somatoform and psychological dissociation
22
Ellert R. S. Nijenhuis
23
hysteria had amnesia, in addition to many somatoform symptoms. Contemporary research also shows that psychological dissociation and somatization
are related phenomena. For example, Saxe et al. (1994) found that about
two-thirds of the patients with dissociative disorders met the DSM-IV criteria
of somatization disorder. Yet somatization probably is neither a distinct clinical entity, nor the result of a single pathological process (Kellner, 1995). It
seems likely that somatoform dissociation pertains to a subgroup of somatoform symptoms that remain medically unexplained, or difficult to explain.
The findings of our studies are more consistent with the ICD-10 (WHO,
1992), that includes dissociative disorders of movement and sensation, than
to the DSM-IV, that restricts dissociation to psychological manifestations and
regards somatoform manifestations of dissociation as conversion symptoms. However, the SDQ-5 in the Netherlands, and the SDQ-20 in Turkey,
were at least as effective as the DES in the screening for DSM-IV dissociative disorders, and our finding that psychological and somatoform dissociation are strongly associated suggests that both phenomena are manifestations
of a common (pathological) process. Moreover, somatoform dissociation has
been demonstrated to be characteristic of DSM-IV conversion disorder (Kuyk,
Spinhoven, Van Emde Boas, & Van Dyck, 1999; for a review, see Bowman &
Kuyk, in press), and somatoform dissociation, rather than psychological dissociation, was characteristic of patients with pseudo-epileptic seizures (Kuyk
et al., 1999). Psychological dissociation was also very common among patients with conversion disorders (Spitzer, Spelsberg, Grabe, Mundt, & Freiberger, 1999).
In conclusion, relabeling conversion (a concept that has links to controversial Freudian theory) as somatoform dissociation, and categorizing the DSMIV conversion disorders as dissociative disorders is indicated. The same
applies to somatization disorder when it is predominantly characterized by
somatoform dissociation. Such findings would promote a reinstitution of the
19th century category of hysteria under the general label of dissociative
disorders, and would include the current dissociative disorders, DSM-IV
conversion disorder/ICD-10 dissociative disorders of movement and sensation, and somatization disorder. On the other hand, analysis of somatoform
dissociation in DSM-IV somatization disorder may also reveal the existence
of various subgroups. It could be that a subgroup of patients with somatization disorder has severe somatoform dissociation, whereas another subgroup
obtains low or modest somatoform dissociation scores. It also seems doubtful
that, for example, conversion disorder and hypochondriasis relate to similar
pathology. Hence, further study of somatoform dissociation in the various
DSM-IV somatoform disorders is needed.
The hypothesized dissociative personality-dependent nature of somatoform dissociation cannot be studied with the regular use of the SDQ-20 and
24
SDQ-5, but must be analysed using other methods. These include repeated
administration of these instruments to DID patients while they remain in
apparently normal and emotional personalities, and to controls while
they maintain simulated apparently normal and emotional personalities. More important approaches, however, include the study of somatoform
dissociative symptoms and concurrent psychophysiological and endocrinological reactions while DID patients and controls remain in these respectively
authentic and enacted personalities as they are experimentally exposed to
memories of trauma (Nijenhuis, Quak et al., 1999) or masked threat cues
(Van Honk et al., 1999).
RECEIVED: 7/10/00
REVISED: 8/01/00 and 8/11/00
ACCEPTED: 8/26/00
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30
SDQ-20
This questionnaire asks about different physical symptoms or body experiences, which you
may have had either briefly or for a longer time.
Please indicate to what extent these experiences apply to you in the past year.
For each statement, please circle the number in the first column that best applies to YOU.
The possibilities are:
1 = this applies to me NOT AT ALL
2 = this applies to me A LITTLE
3 = this applies to me MODERATELY
4 = this applies to me QUITE A BIT
5 = this applies to me EXTREMELY
If a symptom or experience applies to you, please indicate whether a physician has
connected it with a physical disease.
Indicate this by circling the word YES or NO in the column Is the physical cause known?
If you wrote YES, please write the physical cause (if you know it) on the line.
Example:
Extent to which
the symptom or
experience
applies to you
Is the physical
cause known?
Sometimes:
My teeth chatter
I have cramps in my calves
1 2 3 4 5
1 2 3 4 5
NO
NO
YES, namely
YES, namely
If you have circled a 1 in the first column (i.e., This applies to me NOT AT ALL), you do NOT
have to respond to the question about whether the physical cause is known.
On the other hand, if you circle 2, 3, 4, or 5, you MUST circle NO or YES in the Is the
physical cause known? column.
Please do not skip any of the 20 questions.
Thank you for your cooperation.
Here are the questions:
1 = this applies to me NOT AT ALL
2 = this applies to me A LITTLE
3 = this applies to me MODERATELY
4 = this applies to me QUITE A BIT
5 = this applies to me EXTREMELY
Ellert R. S. Nijenhuis
Extent to which
the symptom or
experience
applies to you
31
Is the physical
cause known?
Sometimes:
1. I have trouble urinating
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
NO
YES, namely
32
APPENDIX (continued)
15. It is as if my body, or a part
of it, has disappeared
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
1 2 3 4 5
NO
YES, namely
Before continuing, will you please check whether you have responded to all 20
statements?
You are asked to fill in and place an X beside what applies to you.
21. Age:
years
22. Sex:
female
male
single
married
living together
divorced
widower/widow
24. Education:
number of years
25. Date:
26. Name: